In 1994, McPherson, who became a Scientology adherent at age 18,[3] moved from Dallas, Texas, to Clearwater, Florida, with her employer, AMC Publishing, which was at that time owned by Bennetta Slaughter and operated and staffed primarily by Scientologists. During June 1995, the church placed McPherson in an "introspection rundown" due to perceived mental instability. Lisa completed the rundown, and she attested to the state of Clear in September.[4]

On November 18, 1995, McPherson was involved in a minor car accident. Paramedics initially left her alone because she was ambulatory, but after she began to remove her clothes, the paramedics decided to take her to the hospital. At one point she remarked that she had taken off her clothes in hopes of obtaining counseling.[5] Hospital staff agreed that she was unharmed, but recommended keeping her overnight for observation. Following intervention by fellow Scientologists, McPherson refused psychiatric observation or admission at the hospital and checked herself out after a short evaluation.[6]

Lisa McPherson refused psychiatric observation or admission at the hospital; she expressly stated her desire to receive the religious care and assistance from her fellow congregants that she and they wanted her to have.

McPherson was then taken to the Flag Land Base for "rest and relaxation" according to the Church of Scientology,[8] but sworn statements demonstrate that McPherson was brought there for another introspection rundown.[9][8]

Mark McGarry, an attorney with the Florida Office of the State Attorney, characterized McPherson's stay at the FSO as an "isolation watch":[9]

My understanding now is, from talking to many, many witnesses, the purpose of her being there in the Church, correct me if I'm wrong, she was experiencing some mental problems, and you guys were going to stabilize her through an isolation watch. And after that watch occurred, there was going to be a procedure run on her, and the procedure was an introspection rundown.

The church accommodated McPherson in a cabana and kept a "24 hours' watch" over her. Detailed logs were kept on McPherson’s day-to-day care. These logs were handwritten on plain white paper.[10] Most of these logs were kept but the logs for the last three days were summarized from the originals and the originals shredded. Brian J. Anderson, the then Commanding Officer of the Church's Office of Special Affairs (OSA) in Clearwater, said in his sworn statement:[11]

I saw the handwritten notes, gave a cursory look to see if the summary—see if they matched and matched, and I threw the handwritten reports in my shred basket, and I had the report, kept the report.

McPherson’s "care logs" narrate the last seventeen days of her life: she was incoherent and sometimes violent, her nails were cut so she would not scratch herself or the staff, she bruised her fists and feet while hitting the wall. She had trouble sleeping and was being given natural supplements and the drug chloral hydrate to help her sleep. A Church staffer noted that McPherson "looked ill like measles or chicken pox on her face." On repeated occasions she refused food and protein shakes that the staff offered. On November 26 and 30 and December 3 to 4, the staff attempted to force feed her, noting that she spat the food out. She was noted to be very weak, not standing up nor on some days moving at all.[12] Scientologists who questioned this handling were told to "butt out".[13]

On December 5, 1995, the Church staffers contacted David Minkoff, a Scientologist medical doctor who twice prescribed McPherson Valium and chloral hydrate without examining her.[14] They requested for him to prescribe an antibiotic to McPherson because she seemed to have an infection. Minkoff refused and stated that McPherson should be taken to a hospital and he needed to see her before prescribing anything.[10] They objected, expressing fear that McPherson would be put under psychiatric care.[14] Dr. Janice Johnson, a senior medical officer at Flag Land Base who was assigned to care for McPherson, stated that McPherson had been gasping and had labored breathing while en route. However they passed a total of four hospitals along the way to their ultimate destination. When they arrived at Minkoff's hospital 45 minutes north of Clearwater, McPherson exhibited no vital signs. Hospital staff attempted to resuscitate her for 20 minutes before declaring her dead.[6][15][16][17][18][19][20][21]

Scientologists called McPherson’s family to say that she had died of meningitis or a blood clot[22] on December 5, 1995 while at Fort Murray for “rest and relaxation”.[23] A suspicious death investigation began the next day and an autopsy was performed. A year later, in response to a Clearwater Police Department website request for information on her death, Clearwater media began speculating[24] about the causes of McPherson’s death.[25]

The controversy included regular pickets outside Scientology offices on or around the anniversary of her death.[26]

On December 5, 1995, McPherson’s autopsy was conducted by assistant medical examiner Robert Davis. Davis never completed McPherson’s autopsy report because he was asked to resign from his position.[27] The report identified the cause of death of Lisa McPherson as a thromboembolism of the left pulmonary artery caused by "bed rest and severe dehydration" and the manner of death as "undetermined".[28] The report also identified multiple bruises, an abrasion on the nose, lesions and insect bites that appeared consistent with that of a cockroach.[29] The autopsy report was completed by his supervisor medical examiner Joan Wood.

On January 21, 1997, Wood appeared on the television show Inside Edition and stated that the autopsy showed McPherson's condition had deteriorated slowly, going without fluids for five to ten days, was underweight, had cockroach bites and was comatose from 24 to 48 hours before she died.[30]

The Church of Scientology's legal team proceeded to sue Joan Wood to gain access to Wood's files; including tissue, organ and blood samples from McPherson's body. The lawsuit argued that Wood waived any right to keep her records on the case closed when she spoke openly about the case with news reporters. The Church alleged that the records were needed to start their legal defense. These records were previously denied to the Church because they were part of an ongoing criminal investigation.[31]

The St. Petersburg Times contacted five medical experts for their opinions about the report, and they confirmed Wood's opinion. The Church of Scientology responded that the five doctors should have been given the entire autopsy report, not just the vitreous fluid tests, which pathologists use to determine the composition of blood at the time before death.[32][33]

This scientific evidence was then sent to Joan Wood for review.[35] The scientific evidence sent to Wood included:

Research on compounds known as ketones, which people produce when they are dehydrated, starving or even fasting. Tests of McPherson's bodily fluids showed no ketones according to the pathologists.[1]

Findings from a body measurement expert hired by the church. The Church-hired expert compared autopsy photos of McPherson with those taken shortly before the accident. The expert concluded from the photographs there was "no appreciable weight loss," countering the prosecution's view that McPherson lost 20 pounds (9.1 kg) to 40 pounds (18 kg) while in Scientology's care.[1]

A report by a Morton Plant Hospital doctor and church officials who saw McPherson just before she entered Scientology's Fort Harrison Hotel, stating McPherson was already thin with protruding cheek bones.[36]

A report by Robert D. Davis, the pathologist who conducted the autopsy for Wood's office, concluded McPherson's body was of average nutritional status.[36]

Medical literature and sworn testimony gathered by the church that it says proves the eye fluid samples were improperly handled by Wood's office, incompetently tested at an independent lab and ultimately contaminated.[36]

The plaintiff's response was that the chain of custody of evidence was not broken (also corroborated by assistant State Attorney Douglas Crow's memo to State Attorney Bernie McCabe [37])

Due to the vitreous fluid tests, they maintained that McPherson was dehydrated. Chemical pathologists Calvin Bandt and Werner Spitz concurred with the initial coroner's report in their affidavits.[38] Plaintiff witness Dr. Alan Wu also testified that ketones need not be present for dehydration in a special case like McPherson where she was fed proteins and therefore didn't create measurable ketones.[39] The plaintiffs maintained that Lisa did lose water weight to result in 108 pounds (49 kg) with respect to the vitreous fluid.[40]

In light of the new scientific evidence provided by the church, a review was mandated by the policy manual which says the medical examiner will "readdress key issues" in a case if "credible new evidence is presented, regardless of its source."[1]

After the review Wood changed the cause of death from "undetermined" to an "accident". Wood traced McPherson's pulmonary embolism to her psychosis and a minor auto accident as major factors.[1]

Wood’s review caused the review and dismissal of the Lisa McPherson’s death criminal case.[41] The review was done by assistant State Attorney Douglas Crow and is outlined in the 31 page memo that he sent to State Attorney Bernie McCabe recommending to drop the criminal case against the Church of Scientology.[27]

Crow stated that there were credibility issues with the original autopsy, including that Wood had signed the autopsy herself five months after Davis' departure, failed to examine tissue samples and did not consult clinical experts before reaching her conclusion. He also pointed out two other mistakes done by Wood like releasing the autopsy report on an active criminal case and going public on national media.[27]

Medical examiner Robert Davis changed his testimony from 1997 deposition given in the civil case to strongly disagree that Lisa was severely dehydrated. Also he made a series of accusations against the Medical Examiner's Office's handling of the case and questioned their motive. Davis stated that Wood was not present during the autopsy and did not consult him when she signed the autopsy.[27]

Crow noted that the failure by Medical Examiner's Office to follow its own policies to preserve evidence, releasing the body for cremation before a cause of death had been determined and destroying Davis’ autopsy notes will be used to attack Wood’s credibility.[27]

The primary reason Wood gave for changing her findings was her realization that the microscopic slides of the popliteal vein and the photographs of muscle tissue in the surrounding area provided evidence of trauma which could explain the thrombus formation. She could not explain why she had not seen this before.[27]

Crow was highly critical of Wood in his memo stating:

Her explanations concerning the reasoning behind the changes have been illogical and inconsistent. She vacillated in her conclusions even as she prepared the amended certificate. After talking to Joe Davis she executed a notarized change in the death certificate to accident and removed dehydration and bed rest as causative factors. She then reconsidered that decision and resolved to change the manner of death to homicide with dehydration listed as one of multiple factors and then again changed her mind the next morning, deciding to follow Joe Davis' initial advice.

—Douglas E. Crow

Crow also mentioned a unique set of circumstances that put Wood under tremendous pressure and might have affected the quality of her judgment. These being:

Wood’s appearance on national television left her more vulnerable to litigation and committed her to a forensic position that would make any modification professionally embarrassing.

The fact that Robert Davis, the forensic examiner that actually did the autopsy, was critical of her conclusions.

The defense suggestion that if forced to litigate it would reveal information extremely damaging to Wood's office and her career.

Crow concluded that even though there was probable cause, the actions and testimony of Wood had so muddied the facts that there wasn’t enough credible evidence to prove the case beyond reasonable doubt, and recommended the dismissal of all charges.[27]

While nothing in the review has caused me to believe that the central premises behind the prosecution are erroneous, our ability to establish these necessary facts beyond a reasonable doubt has clearly been compromised. While Dr. Wood is an extremely intelligent and knowledgeable expert who is a formidable witness when defending a valid position, her inability to coherently explain her decision even under benign questioning by me is completely perplexing. Because of Wood's admission of a serious forensic error, her illogical and unfortunately inconsistent justifications of her decision to change the death certificate and autopsy report, the inconsistency between the changes made in the death certificate and the forensic basis for our charges, her continuing equivocation on issues central to the criminal case, and the very real possibility that the cause of death listed by the Medical Examiner's Office is incorrect, I have come to the conclusion that presentation of the Medical Examiner's current testimony to a jury will create a reasonable doubt on crucial forensic issues. When combined with existing problems in the case, it is my recommendation that we should not continue to pursue the prosecution. Douglas E. Crow

December 5 - Lisa McPherson died while under the care of Flag Service Organization (FSO), a branch of the Church of Scientology.

1997

February 19 - The family of Lisa McPherson sued the Church of Scientology and the individuals involved for wrongful death, while the Church claimed it did nothing wrong toward McPherson.[42]

1998

September 15 - Dr. David Minkoff settled his portion of the wrongful death suit by having his malpractice insurance pay $100,000 to the estate.[43]

November 13 - The Church was indicted on two felony charges in McPherson's death; abuse or neglect of a disabled adult, a second-degree felony, and unauthorized practice of medicine, a third-degree felony; the first criminal charges ever filed in the United States against the Church of Scientology.[30] These charges were brought against the Church as a corporation, not against any individuals, and the maximum penalty, had the charges been pursued and the Church found guilty, would have been a $15,000 fine plus costs.[13]

1999

December 6 - Florida State Attorney Bernie McCabe presented a response to Scientology's attempt to get the case dismissed.[44][45]

2000

February 23 - Medical examiner Joan Wood changed the cause of death of Lisa McPherson to an "accident." "Gone from the new report is the original reference to the bed rest and dehydration. Wood still traces the death to a blood clot behind McPherson's knee. But she lists McPherson's psychosis and a minor auto accident as major factors."[1]

March 8 - A group of more than 200 Scientologists moved to have the criminal case dismissed on the claim that it had "chilled the religious rights of every Scientologist" and that other Scientologists were now being treated with concern, suspicion or ridicule by non-Scientologists. A central point of the motion was that McPherson had undergone the Introspection Rundown, which the brief putting forth the motion called an "entirely religious" practice.[46]

April 4 - Scientology moved to have the entire criminal case dismissed. "The entire basis for the state's prosecution of this case has now collapsed," begins one of the many Scientology legal briefs arguing the case should be dismissed.[47]

June 12 - On the advice of Assistant State Attorney Douglas Crow, State Attorney Bernie McCabe dropped the criminal charges against the Church. According to a memo by Crow, medical examiner Joan Wood could not be counted on to confidently testify:

2001

August 3 - Scientologist "OT 8" Dr. David I. Minkoff had his license suspended on for one year and was fined $10,000 for prescribing medicine to McPherson at the request of her FSO caretakers without having ever seen her.[14]

2002

April 29 - The church accused McPherson attorney Ken Dandar of professional misconduct and perjury and tried to get him removed from the case.[48]

August - The church of Scientology sued attorney Ken Dandar for breach of contract, for having added David Miscavige to the wrongful death lawsuit despite a mutual agreement not to add additional defendants. In a 2003 jury trial, Scientology asked for over two million dollars in damages, but received only $4,500 in attorney fees and no punitive damages.[49][50]

2004

May 28 - under terms undisclosed to the public, the civil suit was settled out of court.[2][51]

2009

June 22 - Mark Rathbun, a former member of Scientology, admitted that he had instructed the Church to destroy files related to the case.[52]

2012

October 31 - Ken Dandar filed a federal lawsuit against the Church of Scientology and its attorneys, asking for injunctive relief from the church's litigation, which he claimed was a violation of his civil rights.

November 17 - In support of Dandar's lawsuit, Marty Rathbun claimed in sworn testimony that Scientology spent $30 million to influence Florida judges and defame Dandar during the criminal and civil lawsuits concerning McPherson's death. Rathbun also claimed that Scientology influenced Joan Wood's ruling of McPherson's death as "accident" by bribing her lawyer, Jeffrey Goodis, with Super Bowl tickets and other gifts. Goodis denied the charges.[53]

November 24 - Dandar added David Miscavige as a defendant in his federal lawsuit against Scientology.

As a result of the controversy surrounding the death of Lisa McPherson, the Church of Scientology now requires members to sign a general release form each time they register for a new service, whereby they make certain agreements, such as acknowledging that Scientology is a religion and not intended to treat medical issues, promising not to sue the Church for any reason unless criminal negligence is assured or disavowing psychiatric treatment. In the event a Scientologist is involuntarily placed into a psychiatric ward or institution, the form also grants permission to allow the church to intervene on their behalf and have them released into the care of other Scientologists in order to undergo the Introspection Rundown or any other Scientology services deemed necessary.[55][56]

During the civil suit against the Church of Scientology brought by McPherson's family members, an injunction was sought and obtained to keep the Scientology-critical film The Profit from being shown to avoid prejudicing the jury pool against Scientology.[57]